OBSTETRIC EXAMINATION

Andrei Mihai Măluțan

Educational objectives
What you need to know
 The main elements of the obstetric examination
 Exposing the data collected during anamnesis
 Obstetrical elements assessed through inspection, palpation,
auscultation
 Description of external and internal pelvimetry elements
 The main features of the examination with valves and of the
bimanual vaginal examination

What you need to do

 Abdominal palpation and Leopold manoeuvres
 External and internal pelvimetry
 Examination using valves
 Bimanual vaginal examination

Definition
The obstetric exam is an essential way of establishing the
obstetrical diagnosis and the assessment of pregnancy evolution
until it is completed by birth. It involves professional knowledge,
patience and tact, calmness, consistency, elegance in relation to
the patient, good sense, respecting the woman's chastity, being
easy and quick to adapt to the particular situation, sensing the
patient's mental condition and creating the conditions of some
relationships of mutual affectionateness and trust.
The obstetric examination includes:
 anamnesis
 general physical exam on apparatus and systems
 obstetric clinical examination

Anamnesis
The patient’s personal data (age, marital status,
occupation, urban / rural domicile) will be recorded.
The evaluation of the reasons for the consultation
includes:
 Major emergencies (seizures, umbilical cord prolapse,
haemorrhage, shock)
 Abdominal pain - the following will be analysed: date of
occurrence, primary site, intermittent / continuous, colic or
contractility, irradiation, accompanying symptoms, relation to
a certain position, relationship with rest and / or pain relievers
and antispastic medication
 Amniotic fluid loss
 Bleeding (appearance of bleeding, bleeding duration, amount)
 Other symptoms such as hyperthermia, digestive disorders
(epigastric pain, nausea, vomiting, transit disorders,
hemorrhoids), urinary disorders (polakiuria, dysuria),
refractory intense headache, acute dyspnea, lower limb
oedema
The evaluation of Life and work conditions (dwelling,
monthly income, occupational activity, nutrition, toxic
consumption, family environment) as well as family medical
history (refer to obtaining data on the existence of chronic
diseases of parents, close relatives as diabetes, high blood
pressure, hereditary diseases, genetic diseases, malformation
syndromes, as well as data on the health of the spouse - age, blood
group, Rh, communicable diseases, chronic diseases,
malformations, genetic diseases).
From the personal physiological antecedents the
following shall be recorded:
 Menstrual cycle history - the date of the first menstrual period,
the succession of menstrual cycles: interval, regularity,
duration, quality and quantity of menstrual bleeding,
premenstrual syndrome - dysmenorrhea, mastodynia, age of
onset of sexual life, marriage
 Obstetric antecedents - number of pregnancies, number of
births - spontaneous / caesarean, evolution of childbed,
healthy children and their weight, breastfeeding
Personal pathological antecedents are of particular
importance:
 Obstetrics - spontaneous / provoked abortions, abortion
complications, extopic pregnancies, premature birth, birth
complications, obstetrical manoeuvres (forceps, vidextraction,
manual extraction of placenta), caesarean surgery, postpartum
complications, newborn complications

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 Gynecological - inflammatory / tumoral pathology, genital
surgery, sexually transmitted diseases, Babes-Papanicolaou
(BPN) cytology
 Medical - pathology of various apparatus and systems,
infectious-contagious diseases
 Surgical - extragenital surgery
Current pregnancy history should be evaluated, by
assessing the first day of the last menstruation, the date of first
foetal movement perception, the date of fecund sexual
intercourse, weight gain, oedema, blood pressure oscillations,
treatments administered during pregnancy, registration at a
physician, the rhythm of prenatal examinations, pregnancy
evolution - mentioning the existence of pregnancy-related
conditions, and the reasons for the consultation.

General physical exam on apparatus and systems

The constitution type, height, weight will be appreciated.
The exam on apparatus and systems will note any abnormal
change that may draw attention to an unknown pathology until
then.

Obstetric clinical examination

Inspection
A general obstetric inspection will be carried out with the
facies inspection, observing the chloasma, breasts inspection
observing the pregnancy-induced changes, inspection of abdomen
(size, uterine shape, umbilical modifications, stretch marks, scars,
oedema), and the inspection of vulvo-perineal region indicating
changes induced by pregnancy, ano-vulvar distance (perineum
height), perineal scarring, or haemorrhoids.
Measures in the pregnant uterus
 The fundal height - pregnancy to term 32-34 cm
 Abdominal circumference - pregnancy to term 90-92 cm
Applying Johnson's formula, we can assess the foetus
weight according to the fundal height (FH) and the foetal skull
situation (n). The index n = 12, if the skull is mobile or applied, n
= 11, if the skull is engaged:
(FH– n) x 155 = G in grams of the foetus

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 In the case of pregnant women over 90 kg of body weight,
a corrected formula is applied:
(FH– n - 1) x 155 = G in grams of the foetus

Palpation
Provides information on the following:
 The tonicity of the abdominal wall, being able to sense the
uterine contraction
 The amount of amniotic fluid, being able to appreciate the
abdomen's distensibility
 Foetal state: place, position, presentation, report of the
presentation with the superior pelvic strait
The examination is performed with the patient in dorsal
decubitus, with hips and knees in semiflexion, the examiner
located on the right side of the patient
Palpation is performed following the technique described
by Leopold (Leopold's maneuvers):
 1 - palpation of the pregnant woman's abdomen with the
examiner's hand, assessing the consistency of the uterine wall
 2 - delineation of the uterus fundus and they way it reports to
certain parts: pubic symphysis, umbilicus, xifoid appendix
 3 - palpation of the lower pole of the uterus (lower segment) -
establishing the presentation:
o skull - round, regular, tough pseudotumoral formation,
non depressible
o pelvis - irregular pseudotumoral formation, uneven,
depressible consistency
o transverse position - the lower segment is empty
o on this occasion the ratio that exists between the
presentation and the superior pelvic strait is appreciated
(mobile, applied, fixed, engaged, lowered)
 4 - the area of uterine fundus is palpated, determining the
foetal pole to be distinguished at this level
 5 - Palpation of the uterine flank, defining:
o foetal back - regular plan, hard convex surface, non
depressible
o small foetal parts - irregular, depressible region

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 Figure 1. Leopold's Maneuvers

Auscultation
It is performed with the obstetrical stethoscope,
concomitant with the palpation of the maternal pulse, to
distinguish the maternal sounds from the foetal ones. The location
of the auscultation focal point varies according to the
presentation:
 flexed skull presentation - halfway between the navel and the
anterior superior iliac spine to the part of the foetal back
 pelvic presentation - paraumbilical left or right
 transversal presentation - supra or subumbilical
 facial presentation - halfway between the navel and anterior
superior iliac spine on the opposite side of the foetal back
Foetal heart beats are perceived as rhythmic clock ticks
with a frequency of 120-160 beats / minute, without being
synchronous with the mother's pulse. It can also be noticed:
 umbilical cord souffle - has a fine tonality and overlaps with
foetal heart beats, being caused by an obstacle on uterine
contractions
 uterine souffle - is more blowing, being concomitant with the
maternal pulse. It is determined by uteroplacental circulation

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 foetal movements - which are perceived as irregular kicks,
with diffuse tonality
 pulse of the maternal abdominal aorta
 maternal intestinal noises

Examination of the bony pelvis by external pelvimetry

The following diameters are measured with the aid of the
pelvimeter:
 anteroposterior diameter (Baudelocque's diameter external
conjugate) - the superior edge of the pubic symphysis - 5th
lumbar vertebra (L5) = 20 cm
 bispinous diameter - between the two anterior superior iliac
spines = 24 cm
 intercristal diameter - between the two iliac crests = 28 cm
 bitrohanterian diameter- between the two great trochanters =
32 cm

Figure 2. External pelvimetry

 The aspect of the Rhombus of Michaelis

o vertical diagonal = spinal apophysis L5 - tip of the sacrum
= 11 cm
o horizontal diagonal = between the two posterior superior
iliac spine = 10 cm
o the horizontal diagonal divides the vertical diagonal into
two segments: an upper one of 4 cm and a lower one of 7
cm

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 Figure 3. Rombus of Michaelis

Examination using valves

It supposes the examination of the vagina, cervix,
membrane condition, and a series of paraclinical explorations.
Vaginal examination assesses the colour, presence or absence
of malformations, such as vaginal septa, the presence of
pathological vaginal discharge. Material is collected for vaginal
secretion examination.
Cervical examination appreciates certain parameters that
allow birth prognosis (Bishop score), along with bimanual vaginal
examination. The presence of cervical lesions, the appearance of
external cervical orifice, the appearance of the cervical mucus and
the gelatinous plug shall be assessed.

Table 1. Bishop score

Parameter 0 1 2 3
The position of posterior median anterior
the cervix
Shortening of 30% 40-50% 60-70% 80%
the cervix
The consistency firm average soft
of the cervix
Dilation (cm) 0 1-2 3-4 over 5
The position of high, mobile -2-1 -1-0 +1.+2
the skull
The score is obtained by summing up the 5 parameters. When the score is
over 6, prognosis of vaginal delivery is good.

If there is dilation of the cervix, assess the status of the

membranes (intact, broken) and the amniotic fluid appearance, as
well as the presentation that can be visualized.
Paraclinic examinations include vaginal secretion
examination, cyto-bacteriological examination, Babes-

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Papanicolau cytotumoral examination, amniotic fluid examina-
tion.

Bimanual vaginal examination

It is performed by a bimanual examination, one of the
essential conditions being emptying the bladder before the
examination. The main purpose is exploring the pelvic cavity and
internal genitalia. It will be performed after proper disinfection of
the vulvo-vaginal-perineal region.
The following will be assessed:
 perineum - flexibility, scars
 vaginal walls
 cervix - position, dimensions, consistency, mobility,
sensitivity, external cervical orifice, membrane state, vaginal
fundus
 uterine corpus - position, size, shape, consistency, surface,
mobility, contractility, sensitivity, lateral vaginal fundus,
lower segment
 annexes
 exploring the foetus
o presentation
o position
o variety of position
o relation of the
presentation with the
superior pelvic strait
 fixed - Farabeuf 3
(there is space for 3 Figure 4. Farabeuf manoeuvre
fingers between the presentation and sacrum con-
cavity)
 engaged - Farabeuf 2
 lowered - Farabeuf 1

Bimanual vaginal examination of the bony pelvis allows

internal pelvimetry to be performed

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 Assessment at the level of the pelvic inlet:
 The measuring of the
anteroposterior diameter
of the pelvic inlet, by
trying to reach the
promontorium, noting
where the lower margin of
the pubic symphysis is
located. Normally the
promontory is not
touched. Conjugata vera Figure 5.
(retropubic diameter) Conjugata vera measuring
Is obtained by subtracting 1.5 - 2 cm of the promonto-
suprapubic diameter (diagonal conjugate = 12 cm).
 The usual value of conjugata vera is over 9 cm. In the pelvis
(requiring caesarean section without performing the labour
test), the conjugate vera ≤ 8 cm
 Linea terminalis - usually a palpation of the anterior two thirds
and the posterior third is performed, the sacroiliac joint being
inaccessible for palpation
 The anterior pelvic arch which can be fully explored through
bimanual vaginal examination
 The posterior pelvic arch (the posterior half of pelvic streit)
can not be fully explored
The middle pelvic strait is assessed by appreciating the
sacral concavity (regular, contact with it is lost in the upper third)
and sciatic spines (the bispinous diameter is measured).
In the case of inferior pelvic strait, we shall assess:
 The bischiatic transverse diameter (approximately 11 cm),
permitting the examiner's fist (Greenhill's test)
 Pubic arch angle, which is assessed by marking the lower
margin of the pubis with the two thumbs - normally 80-90‚
 Anteroposterior diameter is approximately assessed by the
appreciation of the sacrococcygeal joint flexibility

Digital rectal examination

It is an examination which can be useful during labour
because it focuses on the presentation, evolution of labour.

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 Establishing medical conduct
After the completion of the obstetric examination of the
pregnant to term, a birth conduct will be established:
 vaginal delivery can take place under normal conditions
 vaginal delivery is contraindicated
 It is necessary to onset birth
If a spontaneous delivery is accepted, the prognosis for
delivery will include:
 maternal prognosis - age, parity, pre-existing pathology,
appropriate delivery preparation
 foetal prognosis - foetal development, gestational age,
presentation
 obstetrical prognosis
o the mechanical component - the pelvic bone, the movable
foetal mass
o dynamic component - uterine contraction characteristics,
membrane condition
o components of the perineum - perineal condition, scras or
sphincter ruptures from previous births

To remember!
 The obstetric exam is an essential way of establishing the
obstetrical diagnosis and the assessment of pregnancy
evolution until it is completed by birth.
 The anamnesis includes the recording of personal data, the
reasons for the consultation, the living and working
conditions, the family medical history, the personal
physiological history, the pathological personal history and
the history of the current pregnancy.
 The obstetric clinical examination consists of inspection,
measurements in the pregnant uterus, palpation, auscultation,
bony pelvis examination by external pelvimetry, valve
examination, bimanual vaginal examination and digital rectal
examination.
 After completion of the obstetrical examination of the
pregnant to term, a delivery conduct shall be established.

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(Self-)Assessment form

Stage / Criteria Correct Incorrect

Performing anamnesis
Measures in the pregnant uterus
Palpation - Leopold manoeuvres
Auscultation of foetal heart in different
presentations
External pelvimetry
Examination using valves
Bimanual vaginal examination

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